Culture is king: What surgeons should know before joining an orthopedic group

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As orthopedic surgery has evolved, culture has become king, according to Nitin Khanna, MD, of Munster, Ind.-based Spine Care Specialists, who believes a short path to partnership, minimum buy-in and a collegial group of surgeon-mentors is ideal for those seeking to join an orthopedic group.

With the razor thin margins of orthopedic care and the hefty student debt for new physicians, most young surgeons are looking for a fair opportunity to work hard and grow.

"If you can provide a great culture and a pathway to success, you will be able to recruit," Dr. Khanna said.

Excellent management, marketing and ancillary service lines will be critical for most private practices to stay viable, but the key ancillary line for young surgeons to evaluate is the ASC.

"If the surgeon is able to make a significant contribution to an ASC, they should be given the opportunity to take an ownership position," he said. "All too often, there are legacy/founding ASC members that believe they are due a premium for risk. Large buy-in and buy-outs also need to be evaluated as these can crush viability of organizations going forward."

Younger surgeons, in particular, would be paying off debt for years to pay out such buy-outs. "This is an antiquated model, and not sustainable," according to Dr. Khanna.

"The historic mantra of 'bigger is better' has come under pressure as managing and cost controls are more challenging once growth is beyond a nine-physician group," he said. "There are certainly benefits for larger organizations, but a pod model with geographic boundaries will better address these concerns."

Surgeons should ask a lot of questions before signing on the dotted line — how many partners will be retiring in three to five years? What are the call responsibilities? Is there a noncompete clause?

Work life balance is key for the next generation of surgeons, who should explore opportunities based on longevity, mentorship and happiness.

"These pieces with hard work solidify the foundation for great organizations," Dr. Khanna said.

Here are more key considerations from two spine surgeons in private practice:

Lali Sekhon, MD, PhD. Nevada Neurosurgery (Reno):

Having done this in 2019 and being 20 years in practice, this is what I looked for:

1. A need for my services. Need to have the volume/demand to support spine.

2. Good people. Good reputation. Had to have the same principles and work ethic.

3. Growing, not shrinking.

4. Put the patient first. Ethical. Principled. Provide appropriate care.

5. Well established ancillaries, such as imaging, physical therapy, urgent care and surgery center.

Two years on, and I could not be happier. 

George Galvan, MD. Texas Neuro Spine (San Antonio):

Key questions:

1. Partnership track, and, if there is one, what does it offer you? Will you be taking on debt from leases and equipment loans, or will it open doors to increased revenue such as ASC partnership and ownership of ancillaries? What is the time to be offered partnership, and cost involved, or buy-in, in becoming a partner?

2. How do they market or promote a new surgeon?

3. Call responsibility?

4. Noncompete clause?

5. Support staff — will you have a midlevel, nurse, medical assistant, etc. If so, how is the cost covered? Are the costs of those positions shared among the doctors?

6. Overhead structure?

7. Has anyone left the practice recently? If so, why? Could their contact be shared so you can speak to them?

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